The effects of enoxaparin on the liver in experimental pneumoperitoneum model

ABSTRACT PURPOSE: To investigate the potential protective effects of enoxaparin against the adverse events of carbon dioxide (CO2) pneumoperitoneum. METHODS: Thirty four rats were divided into three groups: Group 1 (sham) underwent insertion of Veress needle into the abdomen and 90 min of anesthesia with no gas insufflation. The animals in control and enoxaparin groups were subjected to 90 min of 14 mmHg CO2 pneumoperitoneum. Enoxaparin (100 u/kg) was administered subcutaneously to the rats in enoxaparin group one hour before the operation. After 90 min of pneumoperitoneum, the rats were allowed for reperfusion through 60 min. Blood and liver samples were obtained for biochemical and histopathological examination. RESULTS: Treatment with enoxaparin decreased the histopathological abnormalities when compared with the control group. The highest levels of oxidative stress parameters were found in control group. The use of enoxaparin decreased the levels of all oxidative stress parameters, but the difference between the control and enoxaparin groups was not statistically significant. CONCLUSION: Enoxaparin ameliorated the harmful effects of high pressure CO2 pneumoperitoneum on the liver.

Effects of carbon dioxide insufflation on regional cerebral oxygenation during laparoscopic surgery in children: a prospective study / Efeitos da insuflação de dióxido de carbono sobre a oxigenação cerebral regional durante cirurgia laparoscópica em crianças: um estudo prospectivo

ABSTRACT BACKGROUND AND OBJECTIVES: Laparoscopic surgery has become a popular surgical tool when compared to traditional open surgery. There are limited data on pediatric patients regarding whether pneumoperitoneum affects cerebral oxygenation although end-tidal CO2 concentration remains normal. Therefore, this study was designed to evaluate the changes of cerebral oxygen saturation using near-infrared spectroscope during laparoscopic surgery in children. METHODS: The study comprised forty children who were scheduled for laparoscopic (Group L, n = 20) or open (Group O, n = 20) appendectomy. Hemodynamic variables, right and left regional cerebral oxygen saturation (RrSO2 and LrSO2), fraction of inspired oxygen, end-tidal carbon dioxide pressure (PETCO2), peak inspiratory pressure (Ppeak), respiratory minute volume, inspiratory and end-tidal concentrations of sevoflurane and body temperature were recorded. All parameters were recorded after anesthesia induction and before start of surgery (T0, baseline), 15 min after start of surgery (T1), 30 min after start of surgery (T2), 45 min after start of surgery (T3), 60 min after start of surgery (T4) and end of the surgery (T5). RESULTS: There were progressive decreases in both RrSO2 and LrSO2 levels in both groups, which were not statistically significant at T1, T2, T3, T4. The RrSO2 levels of Group L at T5 were significantly lower than that of Group O. One patient in Group L had an rSO2 value <80% of the baseline value. CONCLUSIONS: Carbon dioxide insufflation during pneumoperitoneum in pediatric patients may not affect cerebral oxygenation under laparoscopic surgery.

RESUMO JUSTIFICATIVA E OBJETIVOS: A cirurgia laparoscópica se tornou uma ferramenta cirúrgica popular em comparação com a cirurgia aberta tradicional. Há poucos dados sobre pacientes pediátricos no que se refere ao pneumoperitônio afetar a oxigenação cerebral enquanto a concentração de CO2 no fim da expiração continua normal. Portanto, este estudo teve como objetivo avaliar as alterações da saturação de oxigênio cerebral com espectroscopia de infravermelho próximo durante cirurgia laparoscópica em crianças. MÉTODOS: O estudo recrutou 40 crianças programadas para apendicectomia laparoscópica (Grupo L, n = 20) ou aberta (Grupo A, n = 20). Variáveis hemodinâmicas, saturação de oxigênio cerebral regional direita e esquerda (RrSO2 e LrSO2), fração inspirada de oxigênio, pressão expiratória final de dióxido de carbono (PETCO2), pico de pressão inspiratória (Ppico), volume minuto respiratório, concentrações de sevoflurano inspirado e expirado e temperatura corporal foram registrados. Todos os parâmetros foram registrados após a indução da anestesia e antes do início da cirurgia (T0, basal), 15 minutos após o início da cirurgia (T1), 30 minutos após o início da cirurgia (T2), 45 minutos após o início da cirurgia (T3), 60 minutos após o início da cirurgia (T4) e no fim da cirurgia (T5). RESULTADOS: Houve diminuição progressiva em ambos os níveis de RrSO2 e LrSO2 nos dois grupos, mas não foi estatisticamente significativa em T1, T2, T3, T4. Os níveis de RrSO2 do Grupo L em T5 foram significativamente menores do que os do Grupo A. Um paciente do Grupo L apresentou um valor rSO2 < 80% do valor basal. CONCLUSÕES: A insuflação de dióxido de carbono durante o pneumoperitônio em pacientes pediátricos pode não afetar a oxigenação cerebral em cirurgia laparoscópica.

Ischemia modified albumin: does it change during pneumoperitoneum in robotic prostatectomies?

ABSTRACT Background The unique positioning of the patient at steep Trendelenburg with prolonged and increased intra-abdominal pressure (IAP) during robotic radical prostatectomy may increase the risk of splanchnic ischemia. We aimed to investigate the acute effects of IAP and steep Trendelenburg position on the level of ischemia modified albumin (IMA) and to test if serum IMA levels might be used as a surrogate marker for possible covert ischemia during robotic radical prostatectomies. Patients and Methods Fifty ASA I-II patients scheduled for elective robotic radical prostatectomy were included in this investigation. Exclusion criteria The patients were excluded from the study when an arterial cannulation could not be accomplished, if the case had to be converted to open surgery or if the calculated intraoperative bleeding exceeded 300ml. All the patients were placed in steep (45 degrees) Trendelenburg position following trocar placement. Throughout the operation the IAP was maintained between 11-14mmHg. Mean arterial blood pressure (MAP), cardiac output (CO) were continuously monitored before the induction and throughout the surgery. Blood gases, electrolytes, urea, creatinine, alanine transferase (ALT), aspartate transferase (AST) were recorded. Additionally, IMA levels were measured before, during and after surgery. Results (1) MAP, CO, lactate and hemoglobin (Hb) did not significantly change in any period of surgery (p>0.05); (2) sodium (p<0.01), potassium (p<0.05) and urea (p<0.05) levels decreased at postoperative period, and no significant changes at creatinine, AST, ALT levels were observed in these patients; (3) At the end of surgery (180 min) pCO2, pO2, HCO3 and BE did not change compared to after induction values (p>0.05) but mild acidosis was present in these patients (p<0.01 vs. after induction); (4) IMA levels were found to be comparable before induction (0.34±0.04), after induction (0.31±0.06) ...

Predictive factors of prolonged warm ischemic time (> or =30 minutes) during partial nephrectomy under pneumoperitoneum

PURPOSE: Current clinical data support a safe warm ischemia time (WIT) limit of 30 minutes during laparoscopic partial nephrectomy (LPN) or robot-assisted partial nephrectomy (RPN). We evaluated independent factors predicting prolonged WIT (more than 30 minutes) after LPN or RPN. MATERIALS AND METHODS: A retrospective data review was performed for 317 consecutive patients who underwent LPN or RPN performed by the same surgeon from October 2007 to May 2013. Patients were divided into two groups: group A was defined as prolonged WIT (> or =30 minutes) and group B as short WIT ( or =25 mm; odds ratio, 2.98; 95% confidence interval, 1.48-5.96; p=0.002), and surgeon experience (p<0.001) were independent predictors of prolonged WIT. CONCLUSIONS: Surgeon experience, tumor size, and PADUA score predicted prolonged WIT after RPN or LPN. Among these factors, increasing surgical experience with LPN or RPN is the most important factor for preventing prolonged WIT.

The effect of carbon dioxide pneumoperitoneum on the healing colonic anastomosis in rats

PURPOSE: To investigate the effects of pneumoperitoneum on colonic anastomosis healing. METHODS: Colonic anastomosis was performed in 120 rats divided into four groups: Group I - pneumoperitoneum before laparotomy, Group II - pneumoperitoneum after laparorrhaphy, Group III - pneumoperitoneum before laparotomy and after laparorrhaphy, Group IV - no pneumoperitoneum (control group). Pneumoperitoneum pressure was 5 mmHg. Animals were killed on the 3rd, 7th and 14th postoperative day. Hhistopathological features, anastomosis breaking strength, collagen histomorphometry and hydroxyproline concentration were assessed. RESULTS: Breaking strength between groups: (day 3, p=0.165; day 7, p=0.219; day 14, p=0.539). Histopathology revealed that group II had, on day 7, less infiltration of mononuclear cells (p=0.006), greater infiltration of polymorphonuclear cells (p=0.001) and greater necrosis (p=0.001); and on day 14, less fibrosis. Histomorphometry revealed a decrease in collagen in groups I and III (p<0.001) on day 7 and an increase in groups I and II on day 14 (p<0.001). Hydroxyproline concentration was similar for groups on days 3 (p=0.152), 7 (p=0.913) or 14 (p=0.981). CONCLUSION: Carbon dioxide does not impair the healing of colonic anastomosis in rats.

Effects of pneumoperitoneum with carbon dioxide and helium on renal function and morphology in rats

PURPOSE: To evaluate the effects of pneumoperitoneum with carbon dioxide and helium on renal function and morphology in a rat model. METHODS: Twenty four rats were randomized into three groups (n=8): gasless insufflation ('open', Pressure=0 mmHg), carbon dioxide pneumoperitoneum at 12 mmHg, and helium pneumoperitoneum at 12 mmHg; all lasting 90 minutes.. A cystostomy was performed and the bladder was emptied. At the end of the experiment, the urine produced, a blood sample and the left kidney of each animal were collected. The following variables were obtained: serum sodium, potassium, urea and creatinine, urine volume and creatinine. The creatinine clearance was estimated for each animal. The kidneys were stained with hematoxylin and eosin (HE) and evaluated by a pathologist blinded to the groups. RESULTS: The CO2 and Helium groups did not differ in the variables evaluated. Both developed oliguria (p<0.001 vs. gasless). The CO2 group presented hyperkalemia compared to gasless (p=0.05), which did not attain significance in the helium group. Histopathological analysis revealed mild hydropic degeneration and congestion in the three groups, with no significant difference among them. CONCLUSIONS: The type of gas resulted in no difference in the variables of renal function and morphology assessed. The increase in serum potassium was only observed with CO2 insufflation suggests a combined effect of elevated intra-abdominal pressure and metabolic effects of pneumoperitoneum.

Evaluation of the effects of carbon dioxide pneumoperitoneum on abdominal wall wound healing in rats undergoing segmental resection and anastomosis of the left colon / Avaliação dos efeitos do pneumoperitônio com dióxido de carbono na cicatrização da parede abdominal de ratos submetidos à ressecção segmentar e anastomose no cólon esquerdo

PURPOSE: To evaluate the influence of carbon dioxide pneumoperitoneum on abdominal wall wound healing in rats. METHODS: Eighty rats underwent laparotomy, segmental left colon resection, and anastomosis. The animals were divided into three experimental groups and one control group: EI = pneumoperitoneum for 30 minutes before laparotomy (n=20); EII = pneumoperitoneum for 30 minutes after abdominal closure (n=20); EIII = pneumoperitoneum for 30 minutes before laparotomy and 30 minutes after abdominal closure (n=20); C = control group, without pneumoperitoneum (n=20). In each group, 10 animals were killed 7 days and 10 animals 14 days postoperatively. A segment of the abdominal wall was resected and subjected to tensile strength testing. Another segment of abdominal muscle was used for histopathological analysis; the specimens were fixed in formalin and stained with hematoxylin and eosin. RESULTS: There were no differences in histopathology and tensile strength values among animals in the experimental and control groups 7 or 14 days after surgery. CONCLUSION: Under the present experimental conditions, carbon dioxide pneumoperitoneum did not interfere with abdominal wall wound healing.

OBJETIVO: Avaliar a influência do pneumoperitônio com dióxido de carbono na cicatrização da ferida operatória na parede abdominal de ratos. MÉTODOS: Oitenta ratos foram submetidos à laparotomia, ressecção de segmento do cólon esquerdo e anastomose. Os animais foram distribuídos em quatro grupos de 20 ratos, três experimentais e um controle: Grupo EI = pneumoperitônio por 30 minutos antes da laparotomia. Grupo EII = pneumoperitônio por 30 minutos após a laparorrafia. Grupo EIII = pneumoperitônio por 30 minutos antes da laparotomia e 30 após a laparorrafia. Grupo C = controle, sem pneumoperitônio. Realizou-se, em cada grupo, a eutanásia de 10 animais no 7° e no 14° dia pós-operatório. Um segmento da parede abdominal foi ressecado e submetido à medida da resistência. Outro segmento muscular abdominal foi destinado à análise histopatológica, as peças foram fixadas em formol e as lâminas coradas com hematoxilina e eosina. RESULTADOS: Não houve diferença, à histopatologia e na força de ruptura, entre os animais dos grupos experimentais e do controle no 7° ou 14° dia pós-operatório. CONCLUSÃO: Nas condições em que o experimento foi realizado, o pneumoperitônio com dióxido de carbono não interferiu na cicatrização da parede abdominal.

Punção com agulha de Veress no hipocôndrio esquerdo para a criação do pneumoperitônio: valor diagnóstico das provas de posicionamento da agulha em pacientes não selecionados / Veress needle insertion into the left hypochondrium for creation of pneumoperitoneum: diagnostic value of tests to determine the position of the needle in unselected patients

OBJETIVO: Verificar a eficiência da punção com agulha de Veress no hipocôndrio esquerdo, a acurácia dos testes descritos para o correto posicionamento intraperitoneal da ponta da agulha de Veress em população não selecionada. MÉTODOS: Noventa e um pacientes, sem quaisquer critérios de exclusão, consecutivamente agendados para procedimentos videolaparoscópicos, tiveram a parede abdominal puncionada no hipocôndrio esquerdo. Os pacientes receberam anestesia geral e ventilação controlada mecânica segundo o protocolo. Após a punção foram utilizadas cinco provas para testar o posicionamento da ponta da agulha no interior da cavidade peritoneal: prova da aspiração - PA, da resistência à infusão - Pres, da recuperação do líquido infundido - Prec, prova do gotejamento - PG, e a prova da pressão intraperitoneal inicial - PPII. Os resultados foram considerados para cálculo da sensibilidade (S) e da especificidade (E) e valores preditivos positivos (VPP) e valores preditivos negativos (VPN). Métodos inferenciais estatísticos foram utilizados na análise dos achados. RESULTADOS: Ocorreram 13 fracassos. A PA teve E=100 por cento e VPN=100 por cento. Pres teve S=100 por cento; E=0; VPP=85,71 por cento VPN= não se aplica. Prec: S=100 por cento; E= 53,84 por cento; VPP= 92,85 por cento; VPN= 100 por cento. PG: S=100 por cento; E= 61,53 por cento; VPP= 93,97 por cento VPN= 100 por cento. Na PPII, a S, E, VPP e VPN foram de 100 por cento. CONCLUSÃO: A punção no hipocôndrio esquerdo é eficiente, as provas realizadas orientam o cirurgião a despeito do gênero, IMC ou operações prévias.

Objective: To assess the effectiveness of the Veress needle puncture in the left hypochondrium and the accuracy of the tests described for the intraperitoneal correct positioning of the tip of the Veress needle in an unselected population. Methods: Ninetyone patients consecutively scheduled for Videolaparoscopy had the abdominal wall punctured in the left hypochondrium. There were no exclusion criteria. The patients received general anesthesia and mechanical ventilation according to the protocol. After puncturing five tests were used to confirm the positioning of the needle tip within the peritoneal cavity: aspiration test - AT; resistance to infusion - Pres; recovery of the infused fluid - Prec, dripping test - DT, and test of initial intraperitoneal pressure - IIPP. The test results were compared with results from literature for groups with defined exclusion criteria. The results were used for calculating sensitivity (S) specificity (E), positive predictive value (PPV) and negative predictive value (NPV). Inferential statistical methods were used to analyze the findings. Results: There were 13 failures. AT had E = 100 percent and NPV 100 percent. Pres had S = 100 percent, E = 0; PPV = 85.71 percent; NPV does not apply. Prec: S = 100 percent, E = 53.84 percent, PPV = 92.85 percent, NPV = 100 percent. DT: S = 100 percent, E = 61.53 percent, PPV = 93.97 percent NPV 100 percent. In IIPP, S, E, PPV and NPV were 100 percent. Conclusion: The puncture in the left hypochondrium is effective and the performed tests guide the surgeon regardless of sex, BMI, or previous laparotomy.

The effects of pneumoperitoneum and controlled ventilation on peritoneal lymphatic bacterial clearance: experimental results in rats

OBJECTIVE: To evaluate the effect of pneumoperitoneum, both alone and in combination with controlled ventilation, on peritoneal lymphatic bacterial clearance using a rat bacterial peritonitis model. METHOD: A total of 69 male Wistar rats were intraperitoneally inoculated with an Escherichia coli solution (109 colony-forming units (cfu)/mL) and divided into three groups of 23 animals each: A (control group), B (pneumoperitoneum under 5 mmHg of constant pressure), and C (endotracheal intubation, controlled ventilation, and pneumoperitoneum as in Group B). The animals were sacrificed after 30 min under these conditions, and blood, mediastinal ganglia, lungs, peritoneum, liver, and spleen cultures were performed. RESULTS: Statistical analyses comparing the number of cfu/sample in each of the cultures showed that no differences existed between the three groups. CONCLUSION: Based on our results, we concluded that pneumoperitoneum, either alone or in association with mechanical ventilation, did not modify the bacterial clearance through the diaphragmatic lymphatic system of the peritoneal cavity.

Veress needle related complications in laparoscopic surgery: our experience

A retrospective analytical, multicenteric study conducted to evaluate closed technique for creating pneumoperitoneum in terms of procedural safety. 5244-patients undergoing laparoscopic surgery from January 2001 to December 2009 for different indications in which pneumoperitoneum was created using closed technique by veress needle. Evaluation of results was done by analyzining the data in SPSS V-17. Only 31 [0.6%] patients developed complications like small bowel injury [0.04%], liver injury [0.02%],omental vascular injury [0.13%], omental emphysema [0.19%] and extra peritoneal emphysema [0.2%] while using the closed method for primary access. Only one patient required major intervention while all the rest were managed by simple measure laparoscopically. Closed technique using veress needle for creating pneumoperitoneum is as safe as Hasson's technique and no method has advantage over the other

Preoperative progressive pneumoperitoneum for giant inguinal hernias

Reduction of giant hernia contents into the abdominal cavity may cause intraoperative and postoperative problems such as abdominal compartment syndrome. Preoperative progressive pneumoperitoneum expands the abdominal cavity, increases the patient's tolerability to operation, and can diminish intraoperative and postoperative complications. Preoperative progressive pneumoperitoneum is recommended for giant ventral hernias, but rarely for giant inguinal hernias. We present two giant inguinal hernia patients who were prepared for hernia repair with preoperative progressive pneumoperitoneum and then treated successfully by graft hernioplasty. We observed that abdominal expansion correlated with the inflated volume and pressure during the first four days of pneumperitoneum. Although insufflated gas volume can be different among patients, we observed that the duration of insufflation may be the same for similar patients

O uso do pneumoperitônio progressivo no pré-operatório das hérnias volumosas da parede abdominal / Preoperative progressive pneumoperitoneum in voluminous abdominal wall hernias

CONTEXTO: A correção das hérnias volumosas e dos grandes defeitos da parede abdominal constitui grande desafio da prática cirúrgica, em virtude das dificuldades técnicas e do alto índice de complicações respiratórias e cardiovasculares. OBJETIVOS: Apresentar experiência com a indução do pneumoperitônio progressivo no pré-operatório do tratamento cirúrgico das hérnias volumosas da parede abdominal. MÉTODOS: Estudo retrospectivo de seis pacientes que apresentavam hérnias volumosas da parede abdominal, e que foram operados após a instalação de um pneumoperitônio. O procedimento foi realizado através da colocação de um cateter na cavidade abdominal, na altura do hipocôndrio esquerdo, com insuflação de ar ambiente por período de 10 a 15 dias. RESULTADOS: Dos seis pacientes operados, quatro eram do sexo feminino e dois do masculino. A idade mínima era de 40 e a máxima de 62 anos. A duração da hérnia variou de 5 a 40 anos. Quatro pacientes tinham hérnia incisional, um umbilical e outro inguinal. O tempo médio de pneumoperitônio foi de 11,6 dias. Não houve complicações relacionadas à instalação e manutenção do pneumoperitônio. Todas as hérnias foram corrigidas sem dificuldades técnicas. Utilizou-se a técnica de Lichtenstein para a correção da hérnia inguinal, a transposição peritônio-aponeurótica para uma das hérnias incisionais, sendo as demais corrigidas com uso de tela de polipropileno. Um óbito e uma infecção de parede foram observados no pós-operatório dessas cirurgias. Não houve recidivas registradas até o momento, num período de seguimento de 4 a 36 meses. CONCLUSÃO: O pneumoperitônio progressivo pré-operatório é um procedimento seguro e de fácil execução, pois facilita o procedimento cirúrgico e diminui as complicações respiratórias e cardiovasculares no pós-operatório. É indicado para doentes com hérnias que perderam domicílio na cavidade abdominal.

CONTEXT: Correction of voluminous hernias and large abdominal wall defects is a big challenge in surgical practice due to technical difficulties and the high incidence of respiratory and cardiovascular complications. OBJECTIVES: To present the authors experience with inducing progressive pneumoperitoneum preoperative to surgical treatment of voluminous hernias of the abdominal wall. METHODS: Retrospective study of six patients who presented voluminous hernias of the abdominal wall and were operated after installation of a pneumoperitoneum. The procedure was performed by placing a catheter in the abdominal cavity at the level of the left hypochondrium with ambient air insufflation for 10 to 15 days. RESULTS: Four of the six patients were female and two male. Ages ranged from 42 to 62 years. Hernia duration varied from 5 to 40 years. Four patients had incisional, one umbilical, and one inguinal hernias. Mean pneumoperitoneum time was 11.6 days. There were no complications related to pneumoperitoneum installation and maintenance. All hernias were corrected without technical difficulties. The Lichtenstein technique was used to correct the inguinal hernia, peritoneal aponeurotic transposition for one of the incisional hernias, with the rest corrected using polypropylene mesh. One death and one wall infection were observed post operatively. No recurrences were reported until now, in 4 to 36 months of follow-up. CONCLUSION: Preoperative progressive pneumoperitoneum is a safe and easy executed procedure, which simplifies surgery and reduces post-operative respiratory and cardiovascular complications. It is indicated for patients with hernias that have lost the right of domain in the abdominal cavity.

Dissemination of bacteria labeled with technetium-99m after laparotomy and abdominal insufflation with different CO2 pressures on rats

PURPOSE: To asses the dissemination of bacteria labeled with technetium-99m (99mTc) from peritoneal cavity after different surgical procedures. METHODS: Bacteria of the Escherichia coli species labeled with 99mTc were used in a concentration of 10(8) units of colony-makers for ml (UFC/ml) and 1ml was inoculated through intra-peritoneal via. Forty-eight rats were divided into four groups: control, laparotomy, pneumoperitoneum with 10mmHg and pneumoperitoneum with 20mmHg of CO2. Procedures were performed 20 min after injection of the inoculum and lasted 30 min. Animals were sacrificed after six hours (Group 1) and 24 hours (Group 2). Samples of blood, liver and spleen were collected for radioactivity counting. RESULTS: After six hours, indirect detection of the bacteria in different organs was uniform in all groups. After 24 hours, a larger detection of technetium was observed in the livers of animals of the group insufflated with 20mmHg of CO2, when compared with those of control group (p<0.01). The other groups did not present statistically significant variations. CONCLUSIONS: The use of a higher intra-abdominal pressure was associated with a higher bacterial dissemination to the liver. The application of lower intra-abdominal pressures may be associated with a lower dissemination of the infectious status during laparoscopic approach of peritonitis status.

OBJETIVO: Avaliar a disseminação de bactérias marcadas com tecnécio-99m (99mTc) a partir da cavidade peritoneal após diferentes procedimentos cirúrgicos. MÉTODOS: Foram utilizadas bactérias da espécie Escherichia coli marcadas com 99mTc em uma concentração de10(8) unidades formadoras de colônia por ml (UFC/ml) sendo inoculado 1ml por via intra-peritoneal. Quarenta e oito ratos foram divididos em quatro grupos: controle, laparotomia, pneumoperitôneo com 10 mmHg e pneumoperitôneo com 20 mmHg de CO2. Os procedimentos foram realizados 20 minutos após a injeção do inóculo e duraram 30 minutos. Os animais foram sacrificados após seis horas (grupo 1) e 24 horas (grupo 2). Foram coletadas amostras de sangue, fígado e baço para contagem radioativa. RESULTADOS: Após seis horas, a detecção indireta das bactérias nos diferentes órgãos foi uniforme em todos os grupos. Após 24 horas, observou-se uma maior detecção de tecnécio nos fígados dos animais do grupo insuflado com 20 mmHg de CO2, quando comparados aos do grupo controle (p<0,01). Os outros grupos não apresentaram variações estatisticamente significativas. CONCLUSÕES: A utilização de pressões intra-abdominais mais elevadas associou-se a uma maior disseminação bacteriana para o fígado. A utilização de pressões intra-abdominais menos elevadas na abordagem da peritonite pode estar associada a uma menor disseminação do quadro infeccioso.

Effects of increased intra-abdominal pressure on the healing process after surgical stapling of the stomach of dogs

PURPOSE: To assess the initial healing after surgical stapling of the stomach using a linear cutting stapler and creating pneumoperitoneum (12-14 mmHg) for 60 minutes or 120 minutes, and compare it with the healing of a staple line not submitted to increased pressure. METHODS: A total of 30 dogs were divided into three groups of 10 animals each: Group I (control group - surgical stapling), Group II (surgical stapling and increased intra-abdominal pressure for 60 minutes) and Group III (surgical stapling and increased intra-abdominal pressure for 120 minutes). All dogs were maintained under general anesthesia for two hours after surgical stapling. Seven days after surgery, the area around the staple line was macroscopically and microscopically examined. RESULTS: The macroscopic examination of the samples (n = 30) did not show dehiscence, fistula or abscess. Adhesions between the omentum and the staple line were observed in all animals of Groups II and III (n = 20), which were significantly different from Group I (p = 0.008*). The histopathological analysis showed normal healing up to day 7 in the control animals (n = 10). When these results were compared with those of Groups II and III (n = 20), non-parametric tests revealed that there was a significant difference with regard to certain parameters of the early stages of healing, such as fibroblast migration (p = 0.011*), edema (p < 0.001*) and congestion (p = 0.011*). These alterations affected reepithelization (p < 0.001*), and consequently the late stages of healing. CONCLUSIONS: Each group showed different healing stages, and the healing process was delayed in the groups submitted to increased pressure, especially in the group submitted to increased pressure for longer time.

OBJETIVO: Avaliar os efeitos do pneumoperitônio com CO2 sobre a fase inicial da cicatrização (7° dia) de uma sutura gástrica mecânica em cães, com diferentes tempos de aumento da pressão intra-abdominal. MÉTODOS: Trinta cães foram divididos em três grupos e submetidos à laparotomia mediana e realização de uma sutura vertical na grande curvatura gástrica com grampeador linear cortante. Após a síntese abdominal, nos animais dos grupos II e III instalou-se pneumoperitônio com CO2, permanecendo os animais com pressão intra-abdominal entre 12 e 14 mmHg durante 60 minutos (grupo II) e 120 minutos (grupo III). Os animais foram reoperados no 7° dia, para a avaliação macroscópica da cavidade abdominal e da sutura e retirada de um segmento gástrico contendo essa sutura para análise microscópica. RESULTADOS: Na análise macroscópica observamos diferenças em relação a variável aderência, quando se comparou o grupo controle com os animais dos grupos II e III. Na análise microscópica da fase inicial do processo inflamatório as variáveis edema, congestão e reepitelização apresentaram maiores diferenças estatísticas quando comparados o Grupo Controle com os animais que sofreram a ação do pneumoperitônio. Este fenômeno foi mais evidente nos animais que permaneceram sob ação deste evento por período mais longo. CONCLUSÕES: As suturas submetidas ao aumento de pressão por período mais prolongado (120 minutos) apresentaram retardo do processo de cicatrização quando comparadas àquelas que sofreram essa ação por 60 minutos. Esse fato ficou ainda mais evidente quando as variáveis relacionadas ao processo de cicatrização foram comparadas com o grupo que não sofreu ação do pneumoperitônio.

Repercussões respiratórias e hemodinâmicas do pneumoperitônio na lesão do diafragma: estudo experimental / Hemodynamic and respiratory changes caused by CO2 laparoscopy in an experimental model of diaphragmatic injury

OBJETIVO: Analisar as alterações hemodinâmicas e respiratórias secundárias à laparoscopia em modelo experimental de lesão diafragmática. MÉTODOS: Foram utilizados 15 suínos, distribuídos em três grupos com cinco animais cada, assim constituídos: Grupo 1 - Portadores de lesão diafragmática e avaliados sem pneumoperitônio (CLSP); Grupo 2 - Sem lesão diafragmática e avaliados com pneumoperitônio (SLCP); Grupo 3 - Portadores de lesão diafragmática e avaliados com pneumoperitônio (CLCP). Foram avaliadas variáveis gasométricas, hemodinâmicas e respiratórias. RESULTADOS: Houve alterações significantes da pressão média de artéria pulmonar (PAP), pressão de capilar pulmonar (PCP), PAO2, SAO2 e SVO2. CONCLUSÃO: A videolaparoscopia na presença de lesão do diafragma não acarreta alterações do débito cardíaco e pode ser realizada com segurança, desde que a pressão de pneumoperitônio não ultrapasse valores de 15 mmHg.

OBJECTIVE: The objective of this study was to analyze the hemodynamic and respiratory changes caused by CO2 laparoscopy in an experimental model of diaphragmatic injury. METHODS: Fifteen animals chosen at random were submitted to diaphragmatic injury by means of CO2 laparoscopy. Evaluation consisted of drawing blood samples to analyze blood gases, as well as the hemodynamic and respiratory variables. RESULTS: Alterations occurred in APA, CPP, PAO2, ASO2, VSO2. CONCLUSION: We concluded that videolaparoscopy with pneumoperitoneum pressure under 15mmHg is a safe procedure in patients with diaphragmatic injuries because this pressure level does not cause hemodynamic changes, such as decrease of the cardiac output. [Rev Assoc Med Bras 2007; 53(4): 294-9]

Modificación de la técnica abierta para el neumoperitoneo en cirugía bariátrica por laparoscopia

Se presenta una modificación a la técnica original de acceso abierto para la creación del neumoperitoneo, en pacientes con obesidad clínicamente severa sometidos a cirugía laparoscópica

We present a modification of the original technique for open access to create a pneumoperitoneum, in patients with clinically severe obesity who underwent laparoscopic surgery

Evaluation of tests performed to confirm the position of the Veress needle for creation of pneumoperitoneum in selected patients: a prospective clinical trial

PURPOSE: To evaluate tests performed to confirm the position of the Veress needle inserted into the left hypochondrium for creation of pneumoperitonium. METHODS: One hundred patients were submitted to laparoscopic procedure with left hypochondrium puncturing. Needle positioning tests were evaluated. The aspiration test was considered positive when organic material was aspirated; the injection test was considered positive when no increased resistance to liquid injection was observed; the recovery test was considered positive when the liquid injected was not recovered; the saline drop test was considered positive when drops of saline in the syringe disappeared quickly; the initial intraperitoneal pressure test was considered positive when pressure levels were £ 8 mmHg. A positive aspiration test indicated iatrogenic injury, whereas a positive result in any of the other tests indicated that the tip of the needle was correctly positioned in the peritoneal cavity. Sensitivity (SE), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) of the tests were calculated by correlating results considered true positives (a), false positives (b), false negatives (c) and true negatives (d), according to the formulas: SE = [a/(a + c)] x 100; SP = [d/(b + d)] x 100; PPV = [a/(a + b)] x 100; NPV = [d(c + d)] x 100. RESULTS: With regard to the aspiration test, SE and PPV were not applicable, SP was 100 percent and NPV was 100 percent. With regard to the injection test, SE was 0 percent, SP was 100 percent, PPV was inexistent and NPV was 90 percent. Both recovery and saline drop tests yielded the following results: SE was 50 percent, SP was 100 percent, PPV was 100 percent and NPV was 94.7 percent. The initial intraperitoneal pressure test yielded the following results: SE, SP, PPV and NPV were 100 percent. CONCLUSIONS: When inserting the Veress needle into the left hypochondrium, a negative aspiration test guarantees...

OBJETIVO: Avaliar provas de posicionamento da agulha de Veress introduzida no hipocôndrio esquerdo para criação de pneumoperitônio. MÉTODOS: Cem pacientes foram submetidos a laparoscopia com punção no hipocôndrio esquerdo. Provas de posicionamento da agulha foram avaliadas. A prova da aspiração foi considerada positiva quando sugava-se material orgânico; a prova da resistência foi considerada positiva quando apenas pouca pressão à infusão de líquido era observada; a prova de recuperação foi considerada positiva quando o líquido infundido não era recuperado; a prova do gotejamento foi considerada positiva quando gotas depositadas na agulha escoavam rapidamente; a prova da pressão intraperitoneal inicial foi considerada positiva quando os níveis observados eram d" 8 mmHg. Uma prova de aspiração positiva indicava iatrogenia, ao passo que resultados positivos em todas as outras provas indicavam que a ponta da agulha estava adequadamente posicionada na cavidade peritoneal. Foram calculadas a sensibilidade (S), especificidade (E), valores preditivos positivos (VPP) e negativos (VPN) das provas, mediante correlação dos resultados verdadeiro-positivos (a), falso-positivos (b), falso-negativos (c) e verdadeiro-negativos (d), segundo as fórmulas: S = [a/(a + c)] x 100; E = [d/(b + d)] x 100; VPP = [a/(a + b)] x 100; VPN = [d(c + d)] x 100. RESULTADOS: Na prova da aspiração, constatou-se que S e VPP não puderam ser aplicados, e que E = 100 por cento e VPN = 100 por cento. Na prova da resistência, S = 0 por cento, E = 100 por cento, VPP = não existiu e VPN = 90 por cento. Tanto na prova da recuperação como na do gotejamento, S = 50 por cento, E = 100 por cento, VPP = 100 por cento e VPN = 94,7 por cento. Na da pressão inicial, S, E, VPP e VPN = 100 por cento. CONCLUSÕES: Na punção no hipocôndrio esquerdo, um resultado negativo na prova da aspiração garante ausência de iatrogenia; a prova da resistência não indica com certeza o mau posicionamento...

Veress needle insertion in the left hypochondrium in creation of the pneumoperitoneum / Punção no hipocôndrio esquerdo com agulha de Veress para a criação do pneumoperitônio

PURPOSE: To test the efficacy of the puncture in the left hypochondrium as an alternative method. METHODS: Sixty-two patients randomly distributed into two groups were studied: Group LH, puncture in the left hypochondrium (n=30), and Group ML, puncture in the abdominal midline (n=32). The following were assessed: needle positioning tests, number of failed attempts at needle insertion, and time needed for creation of pneumoperitoneum. Gas flow, volume and intraperitoneal pressure were recorded at every 20 seconds, until a 12 mmHg pressure was reached inside the peritoneal cavity. RESULTS: A similar number of positive results for the needle positioning tests were observed in both groups. Two failed attempts to reach the peritoneal cavity were observed in Group ML and one in Group LH. The time necessary for the creation of pneumoperitoneum was on average 3 minutes and 46 seconds for Group LH, and 4 minutes and 2 seconds for Group ML. Average gas flow, volume and pressure were equivalent for both groups. CONCLUSION: Puncture in the left hypochondrium was as effective as puncture in the abdominal midline for the creation of pneumoperitoneum.

OBJETIVO: Avaliar a eficácia e segurança da punção alternativa no hipocôndrio esquerdo. MÉTODOS: Sessenta e dois pacientes distribuídos aleatoriamente em dois grupos foram estudados prospectivamente: grupo HE, punção no hipocôndrio esquerdo (n=30) e grupo LM, punção na linha média do abdome (n=32). Foram avaliados os testes de posicionamento da agulha, o número de tentativas frustradas e a duração da instalação do pneumoperitônio. Os fluxos correntes, as pressões intraperitoneais e os volumes injetados foram registrados a cada 20 segundos, até 12 mmHg. RESULTADOS: O número de resultados positivos aos testes de posicionamento da agulha foi semelhante em ambos os grupos. Ocorreram duas tentativas infrutíferas de punção no grupo LM e uma no grupo HE. O tempo necessário para o estabelecimento do pneumoperitônio foi, em média, 3 minutos e 46 segundos para o Grupo HE e 4 minutos e 2 segundos para o grupo LM. As médias dos fluxos, das pressões e dos volumes foram respectivamente equivalentes entre os grupos.. CONCLUSÃO: A punção no HE foi tão eficaz no estabelecimento do pneumoperitônio quanto a punção na LM do abdome.

Evaluation of the positioning of the tip of the Veress needle during creation of closed pneumoperitoneum in pigs

OBJETIVO: Estabelecer parâmetros fidedignos do posicionamento adequado da agulha de Veress na cavidade peritoneal durante o estabelecimento do pneumoperitônio pela técnica fechada. MÉTODOS: Em 11 porcos a agulha foi introduzida na cavidade peritoneal através do hipocôndrio esquerdo. Provas de posicionamento da ponta do instrumento foram efetuadas. Insuflou-se CO2 e registraram-se periodicamente pressões, fluxos e volumes. A posição intraperitoneal da agulha foi confirmada e esta foi retirada, sendo re-introduzida no hipocôndrio direito e posicionada sob visão direta no espaço pré-peritoneal. Os mesmos parâmetros foram aferidos. RESULTADOS: A prova do escoamento foi sempre positiva no peritônio. Não se encontrou resistência à introdução de soro no peritônio em nenhum caso, mas sim em 45,5% dos casos no pré-peritônio. Soro algum foi recuperado em 63,5% no peritônio e em 54,5% no pré-peritônio. O gotejamento fluiu livremente em 66,6% das vezes no peritônio e em 45,5% dos casos no pré-peritônio. No peritônio, pressões iniciais de 5,20 mmHg aumentaram progressivamente durante 123 segundos até atingir 15 mmHg. No pré-peritônio a pressão inicial foi de 15,60 mmHg e oscilou entre 12 e 15,60 mmHg. O volume de gás injetado no peritônio foi de 1500 ml e de 100 ml no pré-peritônio. CONCLUSÕES: Aspiração e observação do escoamento e do gotejamento são importantes; recuperar ou não o soro é inconclusivo. Pressão inicial d" 5 mm é indicativo da ponta da agulha no peritônio, onde devem caber dez vezes mais gás que no pré-peritônio. No peritônio os aumentos das pressões e dos volumes pode ser previstos mediante estatísticas.